Autism Spectrum Disorder
DSM-II In DSM-II, this disorder is called Schizophrenia, childhood type For more information, see Schizophrenia This category is for cases in which schizophrenic symptoms appear before puberty. The condition may be manifested by autistic, atypical, and withdrawn behavior; failure to develop identity separate from the mother's; and general unevenness, gross immaturity and inadequacy in development. These developmental defects may result in mental retardation, which should also be diagnosed. DSM-III In DSM-III, this disorder was a category called Pervasive Developmental Disorders Disorders # Infantile Autism # Childhood Onset Pervasive Developmental Disorder # Atypical Pervasive Developmental Disorder DSM-IV In DSM-IV, this disorder was a category called Pervasive Developmental Disorders Disorders # Autistic Disorder # Rett's Disorder # Childhood Disintegrative Disorder # Asperger's Disorder # Pervasive Developmental Disorder NOS DSM-5 Diagnostic Criteria A'. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive): # Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. # Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. # Deficits in developing, maintaining, and understanding relationships, ranging,for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. ''Specify current severity: * '''Level 1 "Requiring support" - Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions. For example, a person who is able to speak in full sentences and engages in communication but whose to-and-fro conversation with others fails, and whose attempts to make friends are off and typically unsuccessful. * Level 2 "Requiring substantial support" - Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others. For example, a person who speaks simple sentences, whose interaction is limited to narrow special interests, and who has markedly odd nonverbal communication. * Level 3 "Requiring very substantial support" - Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning, very limited initiation of social interactions, and minimal response to social overtures from others. For example, a person with few words of intelligible speech who rarely initiates interaction and, when he or she does, makes unusual approaches to meet needs only and responds to only very direct social approaches. B'. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive): # Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). # Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). # High restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). # Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). ''Specify current severity: * '''Level 1 "Requiring support" - Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence. * Level 2 "Requiring substantial support" - Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action. * Level 3 "Requiring very substantial support" - Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action. C'''. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). '''D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E'''. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum and intellectual disability, social communication should be below that expected for general developmental level. '''Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder. Specify if: * With or without accompanying intellectual impairment * With or without accompanying language impairment * Associated with a known medical or genetic condition or environmental factor * Associated with another neurodevelopmental, mental, or behavioral disorder * With catatonia Recording Procedures For autism spectrum disorder that is associated with a known medical or genetic condition or environmental factor, or with another neurodevelopmental, mental, or behavioral disorder, record autism spectrum disorder associated with (name of condition, disorder, or factor) (e.g., autism spectrum disorder associated with Rett syndrome). Severity should be recorded as level of support needed for each of the two psychopathological domains (e.g., "requiring very substantial support for deficits in social communication and requiring substantial support for restricted, repetitive behaviors"). Specification of "with accompanying intellectual impairment" or "without accompanying intellectual impairment" should be recorded next. Language impairment specification should be recorded thereafter. If there is accompanying language impairment, the current level of verbal functioning should be recorded (e.g., "with accompanying language impairment - no intelligible speech" or "with accompanying language impairment - phrase speech"). If catatonia is present, record separately "catatonia associated with autism spectrum disorder." Specifiers The severity specifiers may be used to describe succinctly the current symptomatology (which might fall below level 1), with the recognition that severity may vary by context and fluctuate over time. Severity of social communication difficulties and restricted, repetitive behaviors should be separately rated. The descriptive severity categories should not be used to determine eligibility for and provision of services; these can only be developed at an individual level and through discussion of personal priorities and targets. Regarding the specifier "with or without accompanying intellectual impairment," understanding the (often uneven) intellectual profile of a child or adult with autism spectrum disorder is necessary for interpreting diagnostic features. Separate estimate of verbal and nonverbal skill are necessary (e.g., using untimed nonverbal tests to assess potential strengths in individuals with limited language). To use the specifier "with or without accompany language impairment," the current level of verbal functioning should be assessed and described. Examples of the specific descriptions for "with accompanying language impairment"might include no intelligible speech (nonverbal), single words only, or phrase speech. Language level in individuals "without accompanying language impairment" might be further described by speaks in full sentences or has fluent speech. Since receptive language may lag behind expressive language development in autism spectrum disorder, receptive and expressive language skills should be considered separately. The specifier "associated with a known medical or genetic condition or environmental factor" should be used when the individual has a known genetic disorder (e.g., Rett syndrome, Fragile X syndrome, Down syndrome), a medical disorder (e.g., epilepsy), or a history of environmental exposure (e.g., valproate, fetal alcohol syndrome, very low birth weight). Additional neurodevelopmental, mental, or behavioral conditions should also be noted (e.g., attention-deficit/hyperactivity disorder; developmental coordination disorder; disruptive behavior, impulse-control, or conduct disorders; anxiety, depressive, or bipolar disorders; tic or Tourette's disorder; self-injury; feeding, elimination, or sleep disorders). Catatonia Specifier A'''. The clinical picture is dominated by three (or more) of the following symptoms: # Stupor (i.e., no psychomotor activity; not actively relating to environment). # Catalepsy (i.e., passive induction of a posture held against gravity). # Waxy flexibility (i.e., slight, even resistance to positioning by examiner). # Mutism (i.e., no, or very little, verbal response if known aphasia). # Negativism (i.e., opposition or no response to instructions or external stimuli). # Posturing (i.e., spontaneous and active maintenance of a posture against gravity). # Mannerism (i.e., odd, circumstantial caricature of normal actions). # Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements). # Agitation, not influenced by external stimuli. # Grimacing. # Echolalia (i.e., mimicking another's speech). # Echopraxia (i.e., mimicking another's movements). '''Differential Diagnosis Rett syndrome Disruption of social interaction may be observed during the regressive phase of Rett syndrome (typically between 1-4 years of age); thus, a substantial proportion of affected young girls may have a presentation that meets diagnostic criteria for autism spectrum disorder. However, after this period, most individuals with Rett syndrome improve their social communication skills, and autistic features are no longer a major area of concern. Consequently, autism spectrum disorder should be considered only when all diagnostic criteria are met. Selective mutism In selective mutism, early development is not typically disturbed. The affected child usually exhibits appropriate communication skills in certain contexts and settings. Even in settings where the child is mute, social reciprocity is not impaired, nor are restricted or repetitive patterns of behavior present. Language disorders In some forms of language disorder, there may be problems of communication and some secondary social difficulties. However, specific language disorder is not usually associated with abnormal nonverbal communication, nor with the presence of restricted, repetitive patterns of behavior, interests, or activities. Social (pragmatic) communication disorder When an individual shows impairment in social communication and social interactions but does not show restricted and repetitive behavior or interests, criteria for social (pragmatic) communication disorder, instead of autism spectrum disorder, may be met. The diagnosis of autism spectrum disorder supersedes that of social (pragmatic) communication disorder whenever the criteria for autism spectrum disorder are met, and care should be taken to enquire carefully regarding past or current restricted/repetitive behavior. Intellectual disability (intellectual developmental disorder) without autism spectrum Intellectual disability without autism spectrum disorder may be difficult to differentiate from autism spectrum disorder in very young children. Individuals with intellectual disability who have not developed language or symbolic skills also present a challenge for differential diagnosis, since repetitive behavior often occurs in such individuals as well. A diagnosis of autism spectrum disorder in an individual with intellectual disability is appropriate when social communication and interaction are significantly impaired relative to the developmental level of the individual's nonverbal skills (e.g., fine motor skills, nonverbal problem solving). In contrast, intellectual disability is the appropriate diagnosis when there is no apparent discrepancy between the level of social-communicative skills and other intellectual skills. Stereotypic movement disorder Motor stereotypies are among the diagnostic characteristics of autism spectrum disorder, so an additional diagnosis of stereotypic movement disorder is not given when such repetitive behaviors are better explained by the presence of autism spectrum disorder. However, when stereptypies cause self-injury and become a focus of treatment, both diagnoses may be appropriate. Attention-deficit/hyperactivity disorder Abnormalities of attention (overly focused or easily distracted) are common in individuals with autism spectrum disorder, as is hyperactivity. A diagnosis of attention-deficit/hyperactivity disorder (ADHD) should be considered when attentional difficulties or hyperactivity exceeds that typically seen in individuals of comparable mental age. Schizophrenia Schizophrenia with childhood onset usually develops after a period of normal, or near normal, development. A prodromal state has been described in which social impairment and atypical interests and beliefs occur, which could be confused with the social deficits seen in autism spectrum disorder. Hallucinations and delusions, which are defining features of schizophrenia, are not features of autism spectrum disorder. However, clinicians must take into account the potential for individuals with autism spectrum disorder to be concrete in their interpretation of questions regarding the key features of schizophrenia (e.g., "Do you hear voices when no one is there?" "Yes the radio").